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Instead, STD programs emphasize "yields" from interviews and volume of activity as indirect programmatic indicators of efficacy (CDC, DSTD/HIVP, 1992; Rothenberg and Potterat, in press).
Recent studies suggest that provider referral for STDs, as it is currently performed by disease intervention specialists, is not working effectively. In many programs, fewer than one partner can be found per index patient, although index patients often report having many partners during the interview period (Gunn et al., 1995). A number of factors may contribute to the diminishing utility of provider referral as traditionally carried out in public STD clinics. Concerns about the safety of the interviewers working in high-crime communities, as well as concerns about the cultural sensitivity of the STD interviewers, continue to be raised by both supporters and critics of the process.
Crack cocaine use and the exchange of sex for drugs have emerged as major risk factors in recent epidemics of syphilis (Marx et al., 1991), other STDs (Schwarcz et al., 1992), and HIV infection (Edlin et al., 1994). The large number of often anonymous partners involved in sex-for-drug activities have reduced the efficacy of traditional patient interviewing to identify partners, to the point that many have questioned the continued utility of provider referral in these populations (Andrus et al., 1990; Oxman and Doyle, 1996). Implementing alternative case-finding methods (CDC, 1991a; Engelgau et al., 1995) and refocusing partner outreach toward communities and social networks (Klovdahl et al., 1994; Trotter et al., 1995; Gunn et al., 1995; Rothenberg and Narramore, 1996), rather than traditional partner identification, have been suggested as more effective strategies for reaching high-risk individuals for intervention and prevention activities (Rothenberg and Potterat, in press).
Research evidence concerning the effectiveness of partner notification is sparse at best. Oxman and others (1994) recently reviewed published studies in this area and found the following:
simple forms of assistance for improving patient referral, such as telephone calls, can be effective;
provider referral results in more partners being notified than does patient referral for HIV infection;
evidence supporting provider referral as being more effective than patient referral for syphilis is weak;
evidence is inconsistent regarding the effectiveness of health care professional referral compared with patient referral for gonorrhea and chlamydial infection; and
there is only weak evidence to support the notion that trained interviewers are more effective than regular health care professionals at identifying partners, and there is no evidence that this slightly increased effectiveness has any practical importance for STD prevention.